All-in-One Nursing Care Planning
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1) MCQ
Clinical Scenario
A 58-year-old client is receiving chemotherapy for colon cancer.
On assessment, the nurse notes a temperature of 38.3°C
(101°F), sore throat, and an absolute neutrophil count of
500/mm³.
Question Stem
What is the nurse’s priority action?
Answer Options
A. Encourage oral fluids and recheck temperature in 4 hours
B. Place the client on neutropenic precautions and notify the
provider immediately
C. Give acetaminophen and document the findings
D. Teach the client to increase dietary protein
Correct Answer
B. Place the client on neutropenic precautions and notify the
provider immediately
Detailed Rationale
This client has febrile neutropenia, a medical emergency in
oncology care. The priority is infection prevention and rapid
,escalation because the client has impaired immune defense
and is at high risk for sepsis.
Incorrect Option Analysis
• A: Delays treatment and ignores the emergency.
• C: Antipyretics may mask worsening infection; this is not
the priority.
• D: Nutrition teaching is useful later but does not address
the acute threat.
Nursing Process Linkage
Implementation
NCJMM Competencies
Recognize Cues, Prioritize Hypotheses, Take Action
Difficulty Level
Difficult
Bloom’s Level
Analyze
NCLEX Client Needs
Physiological Adaptation
Nursing Diagnosis Integration
, Priority Nursing Diagnosis: Risk for Infection
Risk Factors: Chemotherapy-induced neutropenia, mucosal
injury
Expected Outcome
The client remains hemodynamically stable and receives
prompt evaluation and treatment for possible infection.
Key Learning Objective
Prioritize emergency actions for a client with chemotherapy-
related neutropenia.
2) SATA
Clinical Scenario
A client receiving chemotherapy asks what actions can reduce
infection risk at home.
Question Stem
Which teaching points should the nurse include? Select all that
apply.
Answer Options
A. Wash hands frequently
B. Avoid people with respiratory infections
C. Eat raw sprouts for extra vitamins
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1) MCQ
Clinical Scenario
A 58-year-old client is receiving chemotherapy for colon cancer.
On assessment, the nurse notes a temperature of 38.3°C
(101°F), sore throat, and an absolute neutrophil count of
500/mm³.
Question Stem
What is the nurse’s priority action?
Answer Options
A. Encourage oral fluids and recheck temperature in 4 hours
B. Place the client on neutropenic precautions and notify the
provider immediately
C. Give acetaminophen and document the findings
D. Teach the client to increase dietary protein
Correct Answer
B. Place the client on neutropenic precautions and notify the
provider immediately
Detailed Rationale
This client has febrile neutropenia, a medical emergency in
oncology care. The priority is infection prevention and rapid
,escalation because the client has impaired immune defense
and is at high risk for sepsis.
Incorrect Option Analysis
• A: Delays treatment and ignores the emergency.
• C: Antipyretics may mask worsening infection; this is not
the priority.
• D: Nutrition teaching is useful later but does not address
the acute threat.
Nursing Process Linkage
Implementation
NCJMM Competencies
Recognize Cues, Prioritize Hypotheses, Take Action
Difficulty Level
Difficult
Bloom’s Level
Analyze
NCLEX Client Needs
Physiological Adaptation
Nursing Diagnosis Integration
, Priority Nursing Diagnosis: Risk for Infection
Risk Factors: Chemotherapy-induced neutropenia, mucosal
injury
Expected Outcome
The client remains hemodynamically stable and receives
prompt evaluation and treatment for possible infection.
Key Learning Objective
Prioritize emergency actions for a client with chemotherapy-
related neutropenia.
2) SATA
Clinical Scenario
A client receiving chemotherapy asks what actions can reduce
infection risk at home.
Question Stem
Which teaching points should the nurse include? Select all that
apply.
Answer Options
A. Wash hands frequently
B. Avoid people with respiratory infections
C. Eat raw sprouts for extra vitamins
